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DACBN: Clinical Nutrition

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Clinical Nutrition

Clinical Nutrition on the DACBN exam tests whether you can translate assessment data into a defensible nutrition diagnosis, intervention, and monitoring plan. Questions emphasize malnutrition definitions, anthropometrics, laboratory interpretation, energy and protein estimation, enteral versus parenteral nutrition, refeeding syndrome, and disease-specific priorities.

Core assessment rules

  • Screen first with a validated tool (MUST, NRS-2002, MNA-SF), then assess intake trends, unintentional weight loss, BMI, muscle/fat loss, functional decline, and inflammation.
  • Diagnose malnutrition using phenotypic plus etiologic criteria (GLIM or ASPEN/AND): weight loss, low BMI, reduced muscle mass, plus reduced intake or inflammation.
  • Do not diagnose malnutrition from albumin or prealbumin alone; both are acute-phase reactants.
  • Energy: indirect calorimetry is preferred. Otherwise use ~25–30 kcal/kg/day for most stable hospitalized adults, adjusting for obesity, critical illness, and refeeding risk.
  • Protein: ~1.2–2.0 g/kg/day in catabolic stress; CKD without dialysis ~0.6–0.8 g/kg/day; dialysis ~1.0–1.2 g/kg/day; obesity use adjusted body weight and higher protein.

Feeding and monitoring

Enteral nutrition is preferred when the gut works; start early in critical illness. Parenteral nutrition is for contraindication or insufficient enteral intake. Refeeding risk rises with low BMI, weight loss, poor intake >5–10 days, and low potassium, magnesium, or phosphate. Start low (10–20 kcal/kg), give thiamine before feeding, and monitor electrolytes daily.

Worked example

A 70 kg woman has BMI 17, 8% weight loss over 3 months, and 10 days of poor intake. Potassium 3.2 mmol/L, magnesium 1.4 mg/dL, phosphate 1.8 mg/dL. She is high risk. Start 10–15 kcal/kg/day (700–1,050 kcal), protein ~1.2 g/kg (84 g), thiamine 100 mg before glucose, and daily K/Mg/Phos checks; advance over 4–7 days rather than starting 25–30 kcal/kg.

Traps

Using albumin as a nutrition marker; overfeeding the obese or critically ill; forgetting thiamine; stopping enteral feeding for a single high gastric residual; missing the electrolyte nadir of refeeding; and interpreting creatinine without accounting for low muscle mass.